Paternalism: Role of father in family and interferes with person’s liberty of action (e.g.

force treatment)
Autonomy: Independent self role of states without external interference (e.g. lettering patient die)
➢ Health care professionals respect patient’s autonomy and are uncomfortable with paternalism
Paternalism is justified when:
● Patient is incompetent to make decisions
● Benefit provided or harm prevented outweighs the loss of independence and any other benefits the patient seeks in
taking the risks in question
Patient’s Rights: Right of information (understanding of sickness and treatment; chargers and drugs usage etc.), refusal,
confidentiality, complaints and medical reports
Informed Consent:
● No medical interventions can be performed on competent adult without their informed and voluntary consent
● Agreement with the physician’s recommendations after considering the risk associated with plan of care
● Mutual decision after taking initiative to discuss with patients about 1) nature of treatment, 2) benefits, risks
(Benefit-Risk Ratio) and consequences of intervention, 3) alternative treatments
➔ Respect patient’s autonomy; enhance patient’s well-being; fulfill legal requirements
Benefits Problems
Engage patient in his own health Do not understand medical information
Enhance patient-doctor relationship Might not want to make decision individually
Thorough review on treatment options Cannot anticipate reactions to future conditions
Reduce discontent and litigation during complications Might make decisions that contradict their best interest
Standards of Competence: Abilities to comprehend and process information and to reason about the consequences of
one’s actions
Understand treatment procedures, major risks and benefits, and make a decision in light of this deliberation
➔ Grey area exists in rival standards of incompetence
Surrogate Decision Marker: A person who will make crucial clinical decisions on behalf of the patient when he is very
sick or unable to communicate his desire about care
● Substituted judgment → patient’s preferences are known
● Best interests → patient’s own interests are not know
Advanced Directives: patients exercise his autonomy, while competent, on making decisions about life-sustaining
treatments during periods of incompetence
➢ Living will: indicate substantive directives (e.g. MRI) in specific circumstances
➢ Durable power of attorney: assign another person authority to perform specified actions on behalf of himself
Benefits Drawbacks
Protect patient against harmful outcomes Lack of explicit instructions
Reduce stress for families and health professionals Restricted to terminally ill case
Prior decision may not be best in current situation
Professional Obligation
Nonmaleficence: not to inflict evil or harm others (e.g. do not kill, cause pain, incapacitate, cause offense)
Beneficence: prevent and remove harm/evil; do or promote good
➔ Nonmaleficence is more stringent than beneficence when there is a conflict of duties

● Health Ethics 2 – Justice, Privacy and Confidentiality, Fitness to Practice

Distributive Justice: Fair, equitable and appropriate allocation of health care resources
➢ Problems arise when scarcity and competition takes place to obtain goods or avoid burdens
Theories of Justice:
A. Libertarian
Protect rights of property and liberty, allowing persons to improve their circumstances and protect their own health
on their own initiative
B. Communitarian
Emphasize the responsibility of the community to the individual and vice versa; services will be provided to fulfill

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 community-endorsed social goals
C. Egalitarian
Persons should receive an equal distribution of health care but not require equal sharing of all possible social benefits
– “fair equality of opportunity”
Loss of privacy: Others obtain information about a person that he/she wants to keep inaccessible; enters “zones of
secrecy, anonymity, seclusion, or solitude” → to be observed, touched, or intruded upon against his/her wishes
Confidentiality: Limits on the dissemination of information disclosed by a person
➢ Respect for persons, build trust, and prevent harmful consequences
Six Data Protection Principles (DPP)
● Personal data collected for purpose directly related to a function and activity of data user
● Lawful and fair collection of adequate data
● Inform data subjects of the purpose and usage of data
✧ Ensure accuracy of data by taking practicable steps
✧ Delete all data upon fulfillment of purpose
● Data shall be used for original stated or directly related purpose unless prior consent given to subject
✧ Data shall be protected against unauthorized access or processing by taking all practicable steps
● Formulate and provide polices and practices in relation to personal data
✧ Individuals have right to access to and correction of their personal data
✧ Data users should comply with above mentioned request within time limit

Handling of Confidential Information, Records and Property

● Protect from improper or inadvertent disclosure, misuse or unauthorized use, loss, damage or corruption
● Obtain prior permission before disclosing any confidential information or records
● Under no circumstances shall we use such information or records for personal gains
Exceptions to Confidentiality
Protect Patients Protect Third Parties
Child abuse Reporting to public officials
Elder abuse Infectious disease
Domestic violence Related to weapons or crimes
Warnings to persons at risk
Violence by psychiatric patients
Fidelity: Obligation to act in good faith to keep vows and promises, fulfill agreements, maintain relationship, and
discharge fiduciary responsibilities
➢ Patient-physician relationship is founded on trust and confidence
Professional Conduct
Integrity and Accountability → decisions made in the best interest of the public instead of personal gain
Fitness to Practice
● Criminal conviction, caution, reprimand & penalty notice for disorder
● Unprofessional behaviours
● Drug or alcohol misuse
● Physical health
● Mental health

● Health Ethics 3 – Patient Safety & Quality of Care

Patient Safety: The absence of preventable harm to a patient during the process of health care
➢ Every point in the process of care-giving contains a certain degree of inherent unsafety
➢ Adverse events may result from problems in practice, products, procedures or system
➢ A serious global public health issue
➢ A complex system-wide effect is needed for patient safety improvements, including performance improvement,
environmental safety and risk management
Around 10% patients visiting the hospital come across with medical adverse events
First do no harm – Non-maleficence
Health care will never be risk-free, but we can make these risks extremely rare rather than so disconcertingly common
Every patient receives safe healthcare, every time, everywhere
Hand hygiene is the most essential measure
Teamwork is very important in provision of healthcare
Causes of Healthcare Errors:
Medical complexity *Miscommunication
Human factors *Poor team work
System failures Training / supervision

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Patient Safety and Risk Management Strategies
1. Safe Culture
Product of the individual and group values, attitudes, competencies and patterns of behavior that determine the
commitment to, and the style and proficiency of an organization’s health and safety programmes
➢ Just, proactive, reporting and learning culture [Open Culture]
2. Safe Design and Safe Practice
Used in order to help prevent or minimize the chance of error occurring
Five areas of patient care related risks: medication, safe intervention, patient’s condition, patient’s care process, and
misidentification
Risk identification & analysis → Risk reduction programmes
2D Barcode scanning system High risk medications
Hand hygience Know drug allergy
Safe surgery Drug administration – 3 checks (prescription, drug,
patient) 5 rights (time, drug, dose, route, patient)
Electronic prescription of medicaiton Rapid delivery system for dispensing
Dilution table for infusion
3. Staff Engagement and Sharing & Learning
Patient safety is everyone’s business

Continuous Quality Improvement (CQI) on Health Care System

Health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with
current professional knowledge
Safe Unintended patient injuries should be avoided
Effective - Service should be provided to all who could benefit, but not to those who are not
likely to benefit, based on scientific knowledge
- Avoid under use of services as well as overuse.
Efficient Avoid waste, including waste of equipment, supplies, ideas, and energy
Timely Reduce waits and sometimes harmful delays for those who receive care
Equitable Should not vary in quality because of a patient’s personal characteristics such as
gender, ethnicity, geographic location, and socioeconomic status
*Patient-centred Providing care that is respectful of and responsive to individual patient preferences,
needs, and values and ensuring that patient values guide all clinical decisions.
Professionals focus on efficiency and effectively, whereas consumers focus more on satisfaction

Patient-Centred Healthcare
5 Principles Patient Engagement
Information Involvement in healthcare policy
Choice & empowerment Expression of opinions (ask and be asked)
Respect Patients’ complaints handling
Access and support Patient’s acquiring of information
Involvement in healthcare policy

● Global Public Health Problem I: Climate Change and Health

Health Policy: A policy that provides all people with the opportunity to prevent sickness and to lead a socially and
economically productive life
Determinants of Health: Biological; individual lifestyle; social/community network; general social, economical,
environmental, political conditions

Climate Change
Any significant changes in measures of climate that last for an extended period of time
➢ Causes: i) natural factors, ii) natural processes, iii) human activities
4 Dimensions Effects/Impacts
Temperature Increase in temperature level
- Vector-borne infections (e.g. Malaria, Dengue Fever) due to more vectors
for transmission → by 2080, 2 billion more people will be at risk of
Dengue
- Malnutrition, hunger and starvation → crop yield in Africa will drop by
50%
- Allergies & airway diseases
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 - Heat exhaustion & heat stroke
- Less cold- related death
Rainfall Changes in Rainfall
- Vector-borne infections due to breeding of microorganisms by pockets
of trapped rainwater
- Dehydration
- Malnutrition, hunger and starvation
- Environmental refugee
*** Rainfall flooding =/= Seawater flooding [contains salt which may pollute
drinking water]
Sea level Rise in Sea Level
*** Due to expansion of sea water surface & ice-cap melting upon heating
- Dehydration & diarrheal cases due to pollution of drinking water and
water used for farming
- Mental health, conflicts and war
- Environmental refugee
- Injuries and death
Extreme weather events More Disasters
- Environmental refugee
- Mental health conflict and war
- Human insecurity
- Injuries and death
*** Does NOT directly lead to earthquake or tsunami etc.
➢ Health impacts can be classified into: i) Non-communicable, ii) communicable, iii) environmental/context related
Greenhouse gases (CO, CH4, N2O, fluorinated gases): increases global temperature and climate changes
Air pollutants (Particulate Matter, O3, NO2, SO2): leads to bad health outcomes
At Risk Population
Everyone is exposed to the impact of climate changes → at different levels of risk depending on exposure to risk factors
Environmental Refugees: People who have been forced to leave their traditional habitat, temporarily or permanently,
because of a marked environmental disruption that jeopardized their existence and seriously affected their quality of life
Urban heat island: increase in average urban temperature
Quantifying/Measuring Real Health Impacts
● Discomfort & mild symptoms [greatest proportion]
● Self-care & self-medicate
● Help-seeking
● Hospital admission & clinic usage
● Death rate [highest severity]
Displacement Effect: impacts occur a certain period of time later, not immediately
➢ Mitigation Strategy is needed to proactively solve the problems instead of just addressing them
5 Steps to Public Health Actions
1. Aware
2. Concern
3. Understand
4. Capable
5. Endorsed
Cobenefits: Joint primary benefits resulting from the selection of one instrument aimed at reaching several targets and
should be counted as a benefit in benefit-costs analyses in the policy selection process
➢ improve health, ii) protect the environment

● Global Public Health Problem II: Air Pollution in Hong Kong

Dry air: 78% nitrogen, 21% oxygen, 0.93% argon, 0.039% carbon dioxide, ~1% water vapour
Air Pollutants: any other particles or gases not part of its normal composition
➢ Ozone (O3), particular matter, carbon monoxide (CO), nitrogen oxides (NO x), sulphur dioxide (SO2), lead
● Causes of air pollution: i) Natural sources (e.g. volcanic eruption, forest fires, dust storm), ii) Human activities
Coal: one of the dirtiest fuels → produces large amount of ash, CO2, SO2, NOx, sulphuric acid and arsenie
Historical events that raised social awareness on air pollution:
● Meuse Valley in Belgium (Dec 1930)
● Donora Valley in US (Oct 1948)
● London Fog in England (Dec 5-9 1952)
➔ High concentration of SO2,→ High number of death
Factors leading to air pollution in China:
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 ● Industrialization → urban development, power generation in factories and power plants using fossil fuels, heavy
traffic including gasoline and diesel-powered motor vehicles
● Temperature inversion [temperature increases with increasing height] → river valleys, terrain or topography traps
pollutants
● Warm and sunny climate → helps form ozone and air pollutant
Major Air Pollutant

Formation Source Properties / Effects

Sulphur Combustion of fossil fuel Ships, especially in ● Highly soluble in water to form sulphurous
Dioxide (SO2) containing sulphur container terminals acid (H2SO3)
● H2SO3 is a strong irritant of respiratory
mucosa → bronchial constricting
● Oxidation of H2SO3 to H2SO4 further form
sulphates SO42-, found in PM
Nitrogen Combination of nitrogen and Motor vehicles ✧ Nitrogen oxides, rather insoluble in water,
Oxides (NOx) oxygen in varying (buses and trucks in may react with water to form nitrous acid
proportions at high roadside), power (HNO2), which further oxidizes to nitric acid
temperature generation and gas (HNO3)
cooking ✧ NO2 used to represent conc. of all oxides
Ozone (O3) Complex reactions involving Air ● Irritates mucus membranes in mouth, nose
sunlight, hydrocarbon and and throat
NO2 ● Breathing difficulties, lung damages, worsens
asthma
Particulate Combustion of fossil fuel in Motor vehicles ✧ Carbon coated with toxic chemicals (e.g.
Matter (PM) motor vehicles polycyclic aromatic hydrocarbons and toxic
[PMx, where x = metals)
diameter or ✧ “Fine” PM: <2.5µm; “ultrafine” PM: 0.01µm –
less in µm] 0.1µm
✧ PM10 causes increased respiratory illness,
lung damages, cancer and premature death
✧ PM2.5 can be lodged in the deepest part of
lungs → more dangerous
✧ HK: 70% of PM10 is made up of PM2.5
People who suffer most from air pollution:
● Elderly
● Individuals with lung diseases (e.g. asthma) and heart disease
● Children and adults in outdoors
Health Impacts of Air Pollution
Epidemiological Studies: studies of the health of large groups of people
Toxicological Studies: studies of the effects of air pollutants on cells or laboratory animals
➢ Air pollution leads to deaths, illnesses of cardiovascular and respiratory system, poor lung function and health
problems in infants
Monitoring Air Quality
HK: EPD uses air quality monitoring stations routinely to monitor concentrations of air pollutants (SO 2, NO2, O3 and PM10)
based on Air Quality Objectives [Established in 1987 under Air Pollution Control Ordinance]
● Many countries have developed ambient air quality standards for the most harmful air pollutants (SO2, SO42-, NO2, O3,
CO, PM10, PM2.5 and H2S)
Air Quality Standards: Legal limits that identify the (i) maximum concentration level and (ii) time an air pollutant can be
present in air before it begins to cause health problems
Air Quality Guidelines: Produced by WHO in 2005
Solution
Inter-disciplinary efforts are required through utilizing expertise in urban planning, technology, policies, public health,
environmental health, and political will and public awareness
● Identify local sources and regional sources of problem
Local sources: implement policies in energy and transport to reduce emissions from major sources
Regional sources: implement environmental, economic and energy policies to foster regional collaboration in air pollution
monitoring and setting emission limits
Personal precautions: do not go jogging when air pollution index is high; wearing a facial mark does not help much; air
cleaner may help

● Global Public Health Problem III: Emerging Infectious Disease

Transmissible Pathogens:
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1. Bacteria
Single-celled organisms without a membrane-bounded nucleus
2. Fungi
Yeast: candida, cryptococcus
Dimorphic: Penicillium, histoplasma, blastomyces, sporothrix, coccidiodes, paracoccidiodes
Mold: Aspergillus, zygomycetes
3. Parasites
Protozoa: diverse group of unicellular eukaryotic organisms
➢ Malaria, enteric amebiasis and intestinal, trypanosomiasis, leishmaniasis, toxoplasmosis, trichomoniasis
Worms (Helminths): polyphyletic group of eukaryotic parasites
➢ Tapeworms, flukes, roundworms
4. Virus
A small infectious agent that is cell-free
5. Prions
An infectious agent composed of protein in a misfolded form

Bacteria, Fungi, Parasites, Virus and Prions

Antimicrobials
(i) Disinfectants, (ii) antibiotics, (iii) antifungals, (iv) antivirals, (v) antiparasitics
● Resistance is an inevitable evolutionary consequence of antibiotic use
Antibiotic Resistance:
● Lots of germs and a few are drug resistant
● Antibiotics kill bacteria causing the illness, as well as good bacteria protecting the body from infection
● Drug-resistant bacteria (possibly mutated) are now allowed to grow and take over [survival of fittest]
● Some bacteria give their drug-resistance to other bacteria, causing more problems
➔ Antibiotics must be used correctly (right drug, dose and time)
Impact of Resistance:
Longer duration of infectiousness, greater cost of treatment, pass on resistance genes to other vulnerable hosts
Infectious Disease: Exposure → Infection → Disease
Epidemiologic Triad: (i) Agent (pathogen), (ii) Host, (iii) Environment [possible vector in between]
➢ Maintain cycle of infection
Infectious Disease Non-Infectious Disease
Focus Pathogen Disease
Diagnosis Strong laboratory basis Clinical
Treatment Cure Long-term management
Public health Rapid Gradual
response
Prevention Vaccination (one time intervention) Managing multiple risk factors

Control of Infectious Disease

An intergrade response is needed through the collaboration of institutions, people, geographies and prevention methods
1. Prevention
Primary prevention: intervention implemented before disease or injury
Secondary prevention: intervention implemented after disease began, but before it is symptomatic;
Tertiary prevention: intervention implemented after a disease established to prevent complications
2. Surveillance
Ongoing systematic collection, collation, analysis and interpretation of data, and dissemination of information to those who
need to know in order that action can be taken
Sentinel surveillance: disease specific by key locations and institutions
Passive surveillance: routine reporting
Active surveillance: going out and looking for cases, including asymptomatic and ones not previously reported
Syndromic surveillance: rapidly identify possible cases during epidemics using broad clinical definitions
3. Detection
Data analysis and verification
➢ Single case may be reportable and 2 cases are sufficient to define an epidemic; deviation from expected threshold
4. Outbreak Investigation
Establish a case definition → Active surveillance → Define population at risk → Formulate hypothesis for source and
spread
5. Containment
● Provide early and effective treatment with quarantine if necessary
● Eliminate point sources and vectors
● Immunization & chemoprophylaxis, community mobilization for hygiene, health-seeking and social distancing
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 Epidemic Curve
A plot of number of cases versus time
➢ Identifying type of exposure and stage of an epidemic
➢ Useful for developing case definition and incubation times for illness
Types of outbreaks: (i) Point source, (ii) Continuous common source (iii) Propagated person to person
Case Control Study
A group with disease compared to a group without disease
➢ Identify important exposures demographic features and risk factors
Norovirus: a “winter vomiting bug” causing gastroenteritis outbreaks in closed settings
Emergency response plans should be in place before outbreak of epidemics

● Global Public Health Problem IV: Non-Communicable Diseases

Rising Threat of Non-Communicable Disease
Non-Communicable Diseases (NCD): an illness that is caused by something other than a pathogen
➢ Rarely cured completely; may have fluctuations in disease course; may need add-on therapy with time; lifestyle
factors usually play a major role
● High prevalence: many leading causes of death in the world are NCDs [2/3 deaths]
● 7 our of 10 leading causes of death in HK are NCDs
● Clustering effects: presence of one disease associated with another
Four main NCDs: (i) cardiovascular disease, (ii) cancers, (iii) diabetes, (iv) chronic lung diseases
High-income people: most died of NCDs; Low-income people: mostly died of infectious disease
Bowel cancer is catching up lung cancer in HK
Depression and Generalized anxiety disorder, Obsessive-compulsive disorder, Panic disorder, Posttraumatic stress
disorder, Social anxiety disorder, Social phobia are closely linked
Metabolic syndrome: diabetes, hypertension, obesity, gout, lipid disorder
Impact of NCDs to our Society
1. “Clustering effect”: presence of one disease closely related to another
2. Individual impact: physical, psychological, social and spiritual disease complications
3. Society impact: decrease in productivity, job absenteeism & turnover
4. Huge public health burden: health service utilization, health care expenditure, side effects of drugs, advanced
technological equipment and expertise sometimes required
Association between Lifestyles and NCDs
✧ Physical inactivity, harmful use of alcohol, tobacco use, unhealthy diet lead to NCD
✧ NCD could lead to premature deaths, mortality, morbidity and disabilities
Reduction of NCDs and controversies
1. Adequate amount of moderate-intensity aerobic physical activity:
%HRmax Method: (220-Age) x 64-76%
%HRR Method: (HRmax – Resting heart rate) x 64-76% + RHR
2. Reduced smoking/e-cigarettes(vaporized nicotine)
● Benefits: help smokers quit, slowly dialing down nicotine levels, no evidence, compete with regular cigarettes
● Harm: nicotine cause CVDs, birth defects, vapor contains toxicants and heavy metals
3. Decrease alcohol consumption
4. Consume 5 or more servings of fruits and vegetables per day
5. Body vibration for fat-burning
6. drinking low calorie soft drink -- artificial sweeteners
● people rely on this are more likely to gain weight, increase appetite and calorie consumption
7. surgery for obesity -- reduce size of stomach, removal of stomach portion, gastric bypass
● Benefits: recovery from diabetes, improve CV risk factors, long term weight loss
● Harm: complications, gastric dumping syndrome, infections, leaking and pneumonia
Challenges Forward
● Aging population
● Westernization and urbanization - westernization of Asian Eating Practice, increased inflammatory bowel disease
● Stress and sedentary lifestyle
● Depression
● people at higher risk of chronic disease are less likely to undergo health check

Strategies to control NCDs

“Upstream” Parable: repair the bridge before it actually falls down → prevention more important than cure
Definition Example
Primary Prevention Prevent altogether the development of a - Health education (smoking cessation
disease process by reducing the risk factors campaign)
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 - Prophylaxis (vaccination & immunization)
- Sanitation
Secondary Prevention Early diagnosis of disease at a pre- - Screening (population-based cervical
symptomatic stage followed by prompt and cancer screening programme)
effective treatment - Periodic assessment of BMI
Tertiary Prevention Minimize harmful effects after detecting More meticulous monitoring of hypertension
disease to reduce the risk of end-organ damage

Telomere: non-gene DNA at the ends of DNA strands in chromosomes, which are shortened during DNA replication, cell
division and DNA damage
➢ Entire loss in telomere would cause the cell to stop replicating or cell death
➢ Length determined by: level of telomerase, age and DNA damage
➔ Adequate telomere length is vital to maintaining cells including immune system cells
➔ Longer telomere length associated with increased resistance to disease and premature death in prostate, breast, lung
and colorectal cancers
Telomerase: an enzyme which restores telomere
➢ Cancer cells have high level of telomerase → immortal cell
Comprehensive positive lifestyle changes increase cellular telomerase activity, which reduces oxidative stress and
inflammation
Free radicals: highly reactive molecules with unpaired electrons which seek out and destroy healthy cells and DNA
➢ Causes oxidative stress that leads to aging
Antioxidant Enzymes: stabilizes free radicals and prevent damage to cells and tissues
✧ Superoxide dismutase (SOD): converts free radicals to H2O2
✧ Catalase: remove H2O2
✧ Glutathione peroxidase: remove H2O2
Nrf2: A protein messenger that activates antioxidant enzymes & down-regulates genes that promote inflammation

● History of Modern Medicine

Period One: 1821-1941 - Malaria
- Smallpox
- Plague
- Spanish Flu
Period Two: 1945-1960 - Cholera
- Diphtheria
- Measles
- Asian flu
- Immunization for Tuberculosis, Poliomyelitis
Period Three: 1960-1997 - Influenza: HK flu
- Viral Hepatitis B
- HIV/AIDS
Period Four: 1997-Present - Avian Influenza (H5N1)
- SARS

Hospital Authority (HA) established in 1990 to facilitate management and distribution of hospital beds
Hong Kong Academy of Medicine (HKAM) established in 1993 to foster development of postgraduate professional
training and set standards
➢ Most popular constituent colleges in HK commercial sector: Radiology, Ophthalmology, Anesthesiology, Dermatology
Family Medicine provides continuing, comprehensive and holistic care for individuals
New challenges of modern era: (i) ageing population, (ii) degenerative diseases, (iii) ethical & philosophical dilemmas